Older persons and persons with underlying health problems are
at increased risk for complications of influenza infection;
however, only 30% of persons aged greater than or equal to 65 years
are vaccinated against influenza each year (1). This report
describes initial efforts by the National Coalition for Adult
Immunization's (NCAI) Influenza and Pneumonia Action Group (IPAG)
to increase influenza vaccination of adults in the United States
during 1990-1993, and highlights National Adult Immunization Week,
October 25-31, 1992.
Project Characteristics

In 1988, the NCAI was formed to increase the awareness of
physicians, other health-care providers, and the general public
about the need for and benefits of adult vaccination. In 1989, the
NCAI convened the IPAG* to conduct disease-specific information and
education activities. During 1990, the IPAG initiated a 3-year
project in eight geographically and demographically diverse project
areas to increase use of influenza and pneumococcal vaccines;
another site was added in 1992.**

In each pilot site, partnerships were established between the
local American Lung Association (ALA) and a state or local health
department; these groups invited key community leaders from
health-care provider and consumer groups to participate in
establishing a community vaccination coalition. Coalition members
were selected based on their efforts in promoting adult
vaccination, particularly influenza and pneumococcal vaccination.

The primary objective of the IPAG is to increase influenza
vaccine coverage as measured by vaccine distribution. Additional
objectives are to 1) collect influenza vaccine delivery data from
public health sites for at least 1 year before project start-up and
for each project year, 2) increase the number of health-care
providers who recommended and provided influenza vaccine to their
patients each year, and 3) increase activities by the local ALA and
community-leader coalitions aimed at improving health-care
providers' awareness of the need for influenza vaccination.

Site-specific data on influenza vaccine distribution were
provided by the four U.S. influenza vaccine manufacturers, and for
six of nine sites, the number of doses of influenza vaccine
distributed by local public health clinics were provided by the
state or local health departments. Program activities continue in
the nine pilot sites, and additional ALA and health department
partners have formed in other areas in the United States.
Project Results

During the 1989-90 influenza season, influenza vaccination
increased in each project site, compared with 1988-89 levels. In
the first year of the project (i.e., the 1990-91 influenza season),
distribution of vaccine doses increased from 2.3% to 23.9% in five
of the eight sites compared with 1989-90 levels -- Minnesota
(23.9%),
South Dakota (11.0%), Washington (10.4%), Mississippi (5.9%), and
Delaware (2.3%). Although declines occurred in three sites (New
York City [-17.7%]; Lee County, Florida [-6.9%]; and Oklahoma
[-6.3%]), distribution in these sites remained above levels in
1988-89. In addition, in two of these sites, vaccine distribution
increased in public health clinics (Lee County [15.0%] and Oklahoma
[14.6%]). Increases (from 4.5% to 22.3%) in public clinic vaccine
distribution also occurred in the six sites reporting data on
health department (i.e., public) clinic vaccine distribution. The
largest increase (23.9%) in overall public and private vaccine
distribution was reported by Minnesota.

Editorial Note

Editorial Note: Although vaccination programs have markedly reduced
the incidence of vaccine-preventable diseases among children,
vaccination programs for adults have been difficult to implement
for at least four reasons: 1) comprehensive adult vaccine-delivery
systems are not available in the public and private sectors; 2)
although statutory requirements exist for vaccination of children,
few such requirements exist for adults; 3) reimbursement mechanisms
and coverage by third-party payors are limited in the public and
private sectors; and 4) vaccination programs have not been
established in most settings where adults congregate (e.g., the
workplace and retirement communities).

Despite these barriers, strategies have been developed that
are effective in enhancing influenza vaccination rates and reducing
influenza-related morbidity and the associated need for health
services (2-6). Most recently, the Medicare Influenza Vaccine
Demonstration increased overall influenza vaccine coverage in 10
demonstration sites from an estimated baseline of 43% in 1988-89 to
approximately 62% in 1991-92 (7) (Health Care Financing
Administration, unpublished data, 1992). In addition, the
California influenza vaccination program has documented steady
increases in influenza vaccine delivery and in overall coverage (8)
(Immunization Unit, California State Department of Health Services,
unpublished data, 1992).

The findings in this report suggest that the collaboration of
public and private organizations in the eight pilot sites was
successful in raising total influenza vaccine doses distributed in
five of the sites. Furthermore, doses distributed through public
clinics increased for all sites that reported data, despite a drop
in overall vaccine distribution in two of these sites, suggesting
that a decrease in vaccine distribution occurred in private
settings. However, other outreach public programs have stimulated
vaccine delivery in private settings (7,9).

Efforts during the third year of the vaccination projects
(i.e., the 1992-93 influenza season) will focus on strengthening
influenza vaccination efforts and expanding to include pneumococcal
vaccination activities. Health-care provider and patient-education
materials about pneumococcal pneumonia will be distributed through
local ALA offices. In addition, influenza and pneumococcal vaccine
distribution during both the second and third years of the project
will be assessed to measure the sustainability of the increases in
vaccine coverage.

The national health objectives for the year 2000 include
increasing to 60% the proportion of older and chronically ill
noninstitutionalized persons who are vaccinated against
pneumococcal and influenza infections (objective 20.11) (10).
Attainment of this objective will require multifaceted strategies
involving collaboration of public and private organizations to
improve awareness regarding vaccine delivery and develop publicly
supported delivery mechanisms that remove cost and accessibility
constraints. National Adult Immunization Awareness Week draws
attention to efforts that promote prevention and control of
vaccine-preventable diseases among adults. Additional information
is available from NCAI; telephone (301) 656-0003.

Members of the NCAI's IPAG include the American Lung Association,
the American College of Physicians, the Association of State and
Territorial Health Officials, the American Health Care Association,
the American Association of Retired Persons, the American
Association of Homes for the Aging, the American Academy of Family
Physicians, the United States Conference of Local Health Officers,
the American Society of Hospital Pharmacists, the Canadian Lung
Association, and CDC.
** The eight sites included the entire states of Delaware,
Minnesota, Mississippi, Oklahoma, South Dakota, and Washington, and
New York City and Lee County, Florida. Colorado was added in 1992.

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